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Bass Underwriters
Bass Underwriters
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About Us
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Locations
Contact Us
Agent Services
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Become an Agent
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Report a Claim
Resource Guide
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Commercial Lines
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Specialty Lines
Agency Portal Login
RPM2
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Agent Information
Are you currently working with a Bass Underwriter?
No
Yes
If Yes, please insert Underwriter
Agency Name
Agency License Number
Mailing Address
Policy Number
E&O Aggregate Limit
FEIN
Select business
Personal
Commercial
DBA
Agency Address
Phone Number
E&O Carrier
Carrier Address
E&O Per Claim Limit
Date Agency Established
Contact Information
Principal/Officer
Name
City
Principal Agent First Name
Agent E-mail
Agent License Number
Agency Owner
State
Zip
Last Name
Accounting Exec E-mail Contact at Agency
Copy of Agent License
Agreements
I authorize Bass Underwriters, Inc. to e-mail policies to the below e-mail address
Yes
No
Print Agency Name
Print Name
Title
Date
Policy E-mail Address for receipt of policies
By (Signature)
Clear
Representations & Warranties
I represent and warrant that the statements made in this application are true to the best of my knowledge, information and belief and that I am fully authorized to sign this application on behalf of:
Print Agency Name
Print Name
Title
Date
Clear
Agency Requirements
Attach W9 Form
Copy of Agency License
Has your company experienced bankruptcy in the past five years?
Yes
No
Have you or anyone in your agency faced State DOI discipline or insurance errors/omissions claims?
Yes
No
If yes, please explain
If yes, please explain